|Year : 2021 | Volume
| Issue : 1 | Page : 20-27
Utility of short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach for a better aesthetic outcome and patient satisfaction
Private Aesthetic Plastic and Reconstructive Surgeon, Bursa, Turkey
|Date of Submission||17-Sep-2019|
|Date of Acceptance||09-Jan-2020|
|Date of Web Publication||31-Dec-2020|
Dr. Ayhan Okumus
Ihsaniye Mah, Ilknur Sok, Bulvar 224 Sitesi B/10 Nilufer, Bursa
Source of Support: None, Conflict of Interest: None
Purpose: The purpose of the study is to evaluate the long-term aesthetic outcome of single-session nipple-sparing mastectomy (NSM) and immediate breast reconstruction operations performed using short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach. Materials and Methods: A total of 23 breast cancer patients (mean age: 32 years, range 21–44 years) who underwent single-session NSM and immediate breast reconstruction operations (bilateral in 9) performed through periareolar or submammary approach were included. Data on patient age, breast cancer characteristics, side of mastectomy and reconstruction, postoperative complications were retrieved from hospital records. Aesthetic outcome (by both patients and plastic surgeon), patient satisfaction (visual analog scale [VAS] scores), and psychological outcome (via body image scale) were evaluated after a median 4-year (range, 9 months–11 years) follow-up. Results: Majority of the patients identified that size of the breast (95.7%), shape of breast (95.7%), breast symmetry (95.7%), scars on the breast (100.0%), nipple-areola complex (100%), and overall aesthetic results (95.7%) fulfilled expectations very much. Physician evaluation also revealed that aesthetic outcome was excellent for majority of patients in terms of breast symmetry (80.7%), breast volume (95.7%), position of submammary fold (95.7%), and overall aesthetic result (95.7%) and all patients in terms of scar appearance on the breast (100.0%). Mean (standard deviation) VAS scores for patient satisfaction were 9.4 (0.8). Total body image scale indicated very good body image in terms of affective (e.g. feeling self-conscious), behavioral (e.g. difficulty in looking at the naked body), and cognitive (e.g. satisfaction with appearance) aspects in all patients. Conclusion: Our findings indicate the utility of short-scar (~4 cm) incisions mimicking breast augmentation incisions in a single-session NSM and immediate breast reconstruction as associated with a low-postoperative complication rate, an excellent aesthetic outcome and a very high patient satisfaction.
Keywords: Aesthetic outcome, immediate breast reconstruction, nipple-sparing mastectomy, patient satisfaction, periareolar, short-scar incisions, submammary
|How to cite this article:|
Okumus A. Utility of short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach for a better aesthetic outcome and patient satisfaction. Turk J Plast Surg 2021;29:20-7
|How to cite this URL:|
Okumus A. Utility of short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach for a better aesthetic outcome and patient satisfaction. Turk J Plast Surg [serial online] 2021 [cited 2021 Jun 14];29:20-7. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/20/305910
| Introduction|| |
A growing increase in the number of patients undergoing mastectomy for breast cancer or prophylactic risk-reducing surgery along with the improved survival of breast cancer patients resulted in consideration of the achievement of acceptable aesthetic outcomes besides the oncological safety to be a significant factor for the preservation of quality of life among survivors.,,, This new focus led to consequent advances in surgical techniques to optimize the aesthetic results for improved self-image and self-confidence among patients undergoing mastectomy and breast reconstruction.
The nipple-sparing mastectomy (NSM), an extension of skin-sparing mastectomy to include the nipple-areola complex (NAC), is a novel surgical approach aimed at avoiding the removal of the NAC and facilitating immediate reconstruction to optimize cosmetic outcomes, while still providing an oncologically safe approach in the cancer setting and for risk reduction surgery.,,,,,,,, Immediate postmastectomy breast reconstruction has been considered to be a potentially less surgically challenging and traumatic approach than delayed reconstruction yielding improved psychosocial and emotional outcomes.,
Accordingly, a combination of NSM with immediate breast reconstruction approach has gained popularity for both therapeutic and prophylactic indications in terms of its potential to achieve the best aesthetic outcome while maintaining oncological safety.,,
Type of skin incision is considered relevant for the optimal surgical, oncological, and cosmetic results related to NSM., Several approaches (i.e., a periareolar incision, a transareolar incision or trans-nipple incision, an inferior or lateral mammary incision, and a superior or inferior hemiperiareolar incision) have been described as alternatives to the classic radial or italic S-skin incision in the upper breast quadrants.,,,, However, there is no consensus in the literature regarding the optimal incision to provide oncological safety alongside a high level of patient satisfaction and an excellent aesthetic outcome.,,,,
Notably, despite significant advances in postmastectomy reconstructive surgery, aesthetic outcomes perceived by patients after reconstructive breast surgery for correction of postmastectomy deformities have been suggested to be inferior to outcomes after purely aesthetic breast augmentation surgery for the improved cosmetic appearance of healthy breasts.,,,,
In this regard, we have hypothesized that using short-scar incisions mimicking breast augmentation incisions for mastectomy and reconstruction operation might improve the aesthetic outcome and enable greater patient satisfaction compared with the purely aesthetic cosmetic breast surgery.
This study was therefore designed to evaluate the utility of short-scar incisions mimicking breast augmentation incisions through a periareolar or submammary approach for a better long-term aesthetic outcome and patient satisfaction after single-session NSM and immediate breast reconstruction operation in breast cancer patients.
| Materials and Methods|| |
A total of 23 breast cancer patients (mean age: 32 years, range 21–44 years) who underwent single-session NSM and immediate breast reconstruction operation (bilateral in 9) performed through a periareolar or submammary approach were included in this single-center study conducted between February 2006 and August 2016. Inclusion criteria comprised adult female patients scheduled to undergo NSM with immediate implant-based reconstruction performed through a periareolar or submammary incision. Patients with extensive skin involvement, areolar or nipple retraction, malignant nipple discharge, or positive intraoperative retroareolar frozen sections were excluded from the study.
We obtained written informed consent from each subject for the operative procedures and the use of patient data for publication purposes.
Data on patient age, histopathological type of breast cancer, family history, BRCA mutation, side of mastectomy and reconstruction, and postoperative complications (implant removal, skin-nipple necrosis, seroma, wound dehiscence, surgical site infection, and hematoma) were retrieved from hospital records. Aesthetic outcome (by both patients and the plastic surgeon), patient satisfaction (visual analog scale [VAS] scores), and psychological outcome (via body image scale) were evaluated after a median 4-year (range, 9 months–11 years) follow-up.
Preoperative markings were made with the patient in both standing and supine positions. The incision site was marked as periareolar or submammary according to the location of the tumor, size of the breast, and ease of mastectomy considered by the general surgeon [Figure 1]. The operations were performed under general anesthesia. Local anaesthetic solution (1000 ml saline, 50 ml 1% lignocaine, and 1 ml 1:1000 epinephrine) was injected subcutaneously and between muscle and breast tissue to enable hemostasis. The general surgeon performed a 4–5 cm (average 4.6 cm) periareolar (in 13 patients) or submammary (in 10 patients) incision for excision of mammary tissue leaving the pectoral fascia intact. An additional axillary incision was made in 7 patients for sentinel node dissection. Frozen sections of the retroareolar tissue were routinely acquired for intraoperative histological diagnosis to confirm that there was no tumor invasion to the NAC borders. In patients with a small tumor-to-skin distance necessitating skin excision, incision, and excision were extended according to oncological safety <2 cm; these patients were not included in the study. After the achievement of hemostasis, a subcutaneous (n = 8) or submuscular (n = 24) implant-based immediate breast reconstruction was performed depending on the thickness of skin flaps. Submusculer prostheses were preferred for flaps thinner than 1 cm, and supramuscles for flaps 1 cm or thicker. Anatomical texture prosthesis was used in 7 patients and round texture prostheses were used in 16 patients. No acellular dermal matrix or a similar product was used during reconstruction. Following placement of a suction drain, subcutaneous, and skin closure was performed in all patients.
|Figure 1: The technique for submammary approach and periareolar approach in nipple-sparing bilateral mastectomy with immediate reconstruction|
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Aesthetic outcome (patient self-assessment and physician assessment)
The subjective aesthetic evaluation included the patient's opinion on the extent to the size of the breast, breast shape, breast symmetry, scars on the breast, NAC, and overall aesthetic result fulfilled expectations. Each category was graded from 0 (not at all) to 3 (very much).
The aesthetic outcome was also assessed by the plastic surgeon based on 6-categories, including breast symmetry, breast volume, the position of submammary fold, scar appearance on the breast, and overall aesthetic result. A scale of six grades was used in each category (6: excellent, 5: good, 4: acceptable, 3: bad, 2: very bad, and 1: not completed reconstruction).
The patient satisfaction was evaluated using VAS scores (possible range 1–10, 10 being most satisfied).
Body image scale
The body image scale is a 10-item scale developed by Hopwood et al. to briefly and comprehensively assess the effective (e.g., feeling self-conscious), behavioral (e.g., difficulty in looking at the naked body), and cognitive (e.g., satisfaction with appearance) aspects of body image in cancer patients. It was designed to be used in all types of cancer or treatment. It is a 4-point scale (0 = not at all and 3 = very much), and the final score is the sum of scores for 10 items, ranging from 0 to 30, with a lower score representing a better body image. Karayurt et al. studied Turkish reliability and validity of BIS in 2015.
| Results|| |
Overall, invasive ductal carcinoma (60.8%) was the most common histopathological diagnosis, while BRCA1 and 2 mutations or family history was positive in 47.8% of patients. Mastectomy and immediate breast reconstruction operations were bilateral in 39.1% of patients and submuscular implants were used for reconstruction in 75.0% of patients [Table 1]. Four patients underwent postoperative radiotherapy, while other patients did not require radiotherapy.
None of the patients had implant removal, skin-nipple necrosis, seroma, wound dehiscence, surgical site infection, or hematoma postoperatively. Overall two patients underwent reoperation for breast reconstruction due to the development of Paget disease in the same breast 5 years after the operation in 1 patient and due to capsule contracture that developed 2 years' postoperatively in 1 patient.
The aesthetic outcome, body image, and patient satisfaction
Considering subjective evaluation of aesthetic outcome, the majority of patients identified that size of the breast (95.7%), breast shape (95.7%), breast symmetry (95.7%) and overall aesthetic results fulfilled expectations extremely well, while scars on the breast (100.0%) and NAC (100.0%) were considered to fulfill expectations very much by all patients [Table 2] and [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13].
|Table 2: Subjective and physician-based aesthetic outcome assessment and patient satisfaction|
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|Figure 2: Case-1: 40-year-old female with right invasive ductal carcinoma|
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|Figure 3: Case-1: The aesthetic outcome of single-session nipple-sparing bilateral mastectomy and breast reconstruction with submammary approach; mastectomy and subcutaneous implant-based reconstruction. Postoperative 1-year|
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|Figure 4: Case-2: 43-year-old female with left ductal invasive carcinoma|
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|Figure 5: Case-2: Aesthetic outcome of single-session nipple-sparing bilateral mastectomy and breast reconstruction with submammary approach; mastectomy and submuscular implant-based reconstruction. Postoperative 1-year|
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|Figure 7: Case-3: Aesthetic outcome of single-session nipple sparing bilateral mastectomy and breast reconstruction with submammary approach; mastectomy and supramuscular implant-based reconstruction. Postoperative 1-year|
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|Figure 9: Case-4: Aesthetic outcome of single-session nipple sparing bilateral mastectomy and breast reconstruction with a periareolar approach; bilateral mastectomy and submuscular implant and fat grafting based reconstruction. Postoperative 2-years|
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|Figure 11: Case-5: Aesthetic outcome of single-session nipple sparing bilateral mastectomy and breast reconstruction with a periareolar approach; mastectomy and supramuscular implant-based reconstruction. Postoperative 2-years|
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|Figure 12: Case-6: 33-year-old female with the left ductal invasive carcinoma|
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|Figure 13: Case-6: Aesthetic outcome of single-session nipple sparing bilateral mastectomy and breast reconstruction with a periareolar approach; bilateral mastectomy and submuscular implant-based reconstruction. Postoperative 1-year|
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Physician evaluation also revealed that aesthetic outcome was excellent for the majority of patients in terms of breast symmetry (80.7%), breast volume (95.7%), position of submammary fold (95.7%), and overall aesthetic result (95.7%) and for all patients in terms of scar appearance on the breast (100.0%) [Table 2].
Mean (standard deviation [SD]) VAS score for patient satisfaction was 9.4 (0.8) [Table 2].
Total body image scale score mean (SD, min-max) was 0.8 (1.8, 0–5) in the overall study population which indicated very positive body image in terms of effective (e.g., feeling self-conscious), behavioral (e.g., difficulty in looking at the naked body), and cognitive (e.g., satisfaction with appearance) aspects in all patients after single-session NSM and immediate breast reconstruction operation. None of the patients identified dissatisfaction with the appearance of the scar, body, or appearance [Table 3]. In this study, the aesthetic superiority of the incision preferences could not be determined.
| Discussion|| |
Our findings revealed excellent aesthetic outcome based on both subjective- and physician-based assessments and very high patient satisfaction with scars and overall body image at a median 4-year postoperative follow-up with the use of periareolar and submammary approaches for single-session NSM and immediate breast reconstruction operations among breast cancer patients.
NSM is considered a technique that preserves the integrity of the body, reduces the feeling of mutilation, improves the cosmetic breast results, and reduces the psychological distress regarding the loss of the breast. Moreover, evolving technologies and techniques to optimize autologous and implant-based breast reconstruction further augmented the aesthetic results.,, Thus, NSM and immediate breast reconstruction should be considered a safe approach associated with a fast recovery and favorable outcome in terms of aesthetic, psychological, and quality of life measures.
However, aesthetic results perceived by patients after reconstructive breast surgery are considered likely to be inferior to outcomes after purely aesthetic breast surgery.,, Notably, in a past study comparing aesthetic outcomes of cosmetic (breast augmentation) and reconstructive surgery via postoperative images of 10 patients presented anonymously to participants who were blinded to clinical details, mean aesthetic outcomes were considered equivalent regardless of surgery type in terms of natural appearance, size, symmetry, and nipple position, whereas breast position scored better after reconstruction and scars were found more favorable after breast augmentation. The authors also noted that participants were more likely to rank outcomes less favorably if they believed the surgery had been for reconstructive rather than cosmetic indications.
In this regard, the use of periareolar or submammary incisions mimicking breast augmentation scars for mastectomy and immediate reconstruction in our study seems to further augment the postoperative aesthetic outcome and patient satisfaction compared with the ideal aesthetic standards of cosmetic breast surgery. This finding also appears to be supported by consideration of the visibility of scarring to be excellent by all patients in our cohort.
There is no consensus in the literature regarding the optimal incision type for NSM., The utility of a hemi-periareolar incision with or without medial-lateral extensions in NSM was reported in a past study indicating this to be an oncologically-safe technique with a high level of patient satisfaction and an excellent aesthetic outcome. In another study on four different non-conventional types of skin incisions for NSM including hemi-periareolar, round block, vertical and wise pattern, no significant difference was reported between the four types of incisions with regard to overall postoperative surgical complications and satisfaction with breasts and psychosocial, physical (chest and abdomen), and sexual well-being. Authors emphasized that these approaches, being more sophisticated than the classical radial incision, are safe in terms of overall and specific postoperative complications provided that they are performed based on rigorous patient selection criteria and by experienced surgeons.
Our data indicates the safety and reliability of using short-scar (~4 cm) periareolar and submammary approaches in NSM and immediate breast reconstruction based on low complication rates in the early postoperative period as well as the satisfactory long-term results with a favorable aesthetic outcome and high patient satisfaction. This result emphasizes the achievement of a texturally accurate, symmetric, and aesthetically appropriate breast reconstruction consistent with the criteria for the “ideal” breast reconstructive technique (1), which seems significant given the positive correlations between aesthetic outcome and quality of life.,,
With a long-term follow-up for a median 4 years after NSM and immediate reconstruction, our findings provide reliable data on complication rates given the continued change in the breast shape postoperatively as well as the potential long-term effects of irradiation.,,,
In addition, given the presence of BRCA mutation carriage necessitating prophylactic contralateral mastectomy for risk-reducing purposes in nearly half of the patients, our findings also support the association of NSM in these patients with a low rate of complications and risk of breast cancer indicating long-term oncological safety of NSM in BRCA gene mutation-positive patients.,
NSM and immediate reconstruction is an increasingly popular procedure in selected patients for either therapeutic or prophylactic reasons in according to the increased numbers of mastectomies and higher patient expectations regarding the cosmetic and psychosocial outcomes.,,,,, Accordingly, our findings indicate that use of incisions mimicking breast augmentation incisions in the single-session mastectomy and reconstruction operation may be an alternative not only to maximize cosmetic outcomes but also with potential psychological benefits by avoiding feelings of loss arising from mutilation and enabling better coping with the traumatic experience of breast cancer.,,
Certain limitations to this study should be considered. First, a relatively small patient cohort limits the generalizing our findings to the overall breast cancer population. Second, the lack of data on quality of life assessment is another limitation which otherwise would extend the knowledge achieved in the current study. Nonetheless, providing data on the long-term follow-up enabling appropriate assessment of potential long-term complications and use of patient self-evaluation in the evaluation of outcome, our findings demonstrate the safety and feasibility of our novel approach.
| Conclusion|| |
Our findings indicate the utility of short-scar (~4 cm) incisions mimicking breast augmentation incisions in a single-session NSM and immediate breast reconstruction as associated with a low-postoperative complication rate, an excellent aesthetic outcome, and a very high patient satisfaction.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that names and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
[Table 1], [Table 2], [Table 3]